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1999 | ANESTHESIOLOGY GROUP | CPT | Limited to DEXA method only, once every 12 months. 6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage." 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. |
1999 | ANESTHESIOLOGY GROUP | CPT | 6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage." 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. |
76075 | Dxa bone density, axial | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76071 | Ct bone density, peripheral | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76077 | Dxa bone density/v-fracture | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76076 | Dxa bone density/peripheral | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76077 | Dxa bone density/v-fracture | HCPCS | 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. |
76077 | Dxa bone density/v-fracture | HCPCS | Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. |
76077 | Dxa bone density/v-fracture | HCPCS | Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. |
G0130 | Single energy x-ray study | HCPCS | Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. |
76077 | Dxa bone density/v-fracture | HCPCS | HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. |
G0130 | Single energy x-ray study | HCPCS | HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. |
76077 | Dxa bone density/v-fracture | HCPCS | ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. |
G0130 | Single energy x-ray study | HCPCS | ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. |
76075 | Dxa bone density, axial | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
76077 | Dxa bone density/v-fracture | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
G0130 | Single energy x-ray study | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
76076 | Dxa bone density/peripheral | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
76075 | Dxa bone density, axial | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
Q9952 | Inj Gad-base MR contrast,1ml | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
G0130 | Single energy x-ray study | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
76076 | Dxa bone density/peripheral | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
76075 | Dxa bone density, axial | HCPCS | Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. 12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. |
Q9952 | Inj Gad-base MR contrast,1ml | HCPCS | Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. 12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. |
76076 | Dxa bone density/peripheral | HCPCS | Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. 12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0360 | Each additional hr 1-8 hrs | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0362 | Each add sequential infusion | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0359 | Chemotherapy IV one hr initi | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86826 | Hla x-match noncytotoxc addl | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86825 | X-MATCHAHG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0360 | Each additional hr 1-8 hrs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0362 | Each add sequential infusion | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0359 | Chemotherapy IV one hr initi | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0360 | Each additional hr 1-8 hrs | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0359 | Chemotherapy IV one hr initi | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38241 | Transplt autol hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38240 | Transplt allo hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0265 | Cryopresevation Freeze+stora | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38242 | Transplt allo lymphocytes | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0266 | Thawing + expansion froz cel | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
96445 | Chemotherapy, intracavitary | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0267 | Bone marrow or psc harvest | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
38241 | Transplt autol hct/donor | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
38240 | Transplt allo hct/donor | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
G0265 | Cryopresevation Freeze+stora | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
38242 | Transplt allo lymphocytes | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
G0266 | Thawing + expansion froz cel | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
96445 | Chemotherapy, intracavitary | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. |
G0267 | Bone marrow or psc harvest | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
38241 | Transplt autol hct/donor | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
38240 | Transplt allo hct/donor | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
G0265 | Cryopresevation Freeze+stora | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
38242 | Transplt allo lymphocytes | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
G0266 | Thawing + expansion froz cel | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
96445 | Chemotherapy, intracavitary | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. |
G0267 | Bone marrow or psc harvest | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number L.8.01.405 added. Investigative definition updated in Policy Guidelines section. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
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